Pop quiz: What aging health problem is extremely common, has serious implications for an older person’s health and wellbeing, and can often – but not always – be prevented?
It’s delirium. In my opinion, this is one of the most important aging health problems for older adults to be aware of. It’s also vital for family caregivers to know about this condition, since families can be integral to preventing and detecting delirium.
In this article, I’ll explain just what delirium is, and how it compares to dementia. Then I’ll share 10 things you should know, and what you can do.
What is Delirium
Delirium is a state of worse-than-usual mental confusion, brought on by some type of unusual stress on the body or mind. It’s sometimes referred to as an “acute confusional state,” because it develops fairly quickly (e.g., over hours to days), whereas mental confusion due to Alzheimer’s or another dementia usually develops over a long time.
The key symptom of delirium is that the person develops difficulty focusing or paying attention. Delirium also often causes a variety of other cognitive symptoms, such as memory problems, language problems, disorientation, or even vivid hallucinations. In most cases, the symptoms “fluctuate,” with the person appearing better at certain times and worse at other times, especially later in the day.
Delirium is usually triggered by a medical illness, or by the stress of hospitalization, especially if the hospitalization includes surgery and anesthesia. However, in people who have especially vulnerable brains (such as those with Alzheimer’s or another dementia), delirium can be provoked by medication side-effects or less severe illnesses.
It’s much more common than many people realize: about 30% of older adults experience delirium at some point during a hospitalization.
That confusion after surgery that older adults often experience? That’s delirium.
The way your elderly mother with dementia gets twice as confused when she has a urinary tract infection? That’s delirium too.
Or the common phenomenon of “ICU psychosis”? That too is delirium.
What Causes Delirium?
In older adults, delirium often has multiple causes and contributors. These can include:
- Infection (including UTI, pneumonia, the flu, COVID)
- Other serious medical illness (e.g. heart attack, kidney failure, stroke, and more)
- Metabolic imbalances (e.g. abnormal blood levels of sodium, calcium, or other electrolytes)
- Dehydration
- Medication side-effects
- Sleep deprivation
- Uncontrolled pain
- Sensory impairment (e.g. poor vision and hearing, which can worsen if the person is lacking their usual glasses or hearing aids)
- Alcohol withdrawal
Delirium vs. Dementia
People often confuse delirium and dementia (such as Alzheimer’s disease), because both conditions cause confusion and appear superficially similar. Furthermore, people with dementia are actually quite prone to develop delirium. That’s because delirium is basically a reflection of the brain going haywire when it gets overloaded by the stress of illness or toxins, and brains with dementia get overloaded more easily.
In fact, the more vulnerable a person’s brain is, the less it takes to tip them into delirium. So a younger person generally has to be very very sick to become delirious. But a frail older person with Alzheimer’s might become delirious just from being stressed and sleep-deprived while in the hospital.
Why Delirium is Such an Important Problem
There are three major reasons why delirium is an important problem for us all to prevent, detect, and manage.
First, delirium is a sign of illness or stress on the body and mind. So if a person becomes delirious, it’s important to identify the underlying problems – such as an infection or untreated pain – and correct them, so that the person can heal and improve.
The second reason delirium is important is that a confused person is at higher risk for falls and injuries during the period of delirium.
The third reason is that delirium often causes serious consequences related to health and well-being.
In the short-term, delirium increases the length of hospital stays, and has been linked to a higher chance of dying during hospitalization. In the longer-term, delirium has been linked to worse health outcomes, such as declines in independence, and even acceleration of cognitive decline.
Now let’s cover 10 more important facts you should know about delirium, especially if you’re concerned about an aging parent or other older relative.
10 Things to Know About Delirium, and What You Can Do
1.Delirium is extremely common in aging adults.
Almost a third of adults aged 65 and older experience delirium at some point during a hospitalization, with delirium being even more common in the intensive care unit, where it’s been found to affect 70% of patients. Delirium is also common in rehabilitation units, with one study finding that 16% of patients were experiencing delirium.
Delirium is less common in the outpatient setting (e.g. home, assisted-living, or primary care office). But it still can occur when an older adults gets sick or is affected by medications, especially if the person has a dementia such as Alzheimer’s.
What to do: Learn about delirium, so that you can help your parent reduce the risk, get help quickly if needed, and better understand what to expect if your parent does develop delirium. You should be especially be prepared to spot delirium if your parent or loved one is hospitalized, or has a dementia diagnosis. Don’t assume this is a rare problem that probably won’t affect your family. For more on hospital delirium, see Hospital Delirium: What to know & do.
2. Delirium can make a person quieter.
Although people often think of delirium meaning as a state of agitation and or restlessness, many older delirious people get quieter instead. This is called hypoactive delirium. It’s still linked with difficulty focusing attention, fluctuating symptoms, and worse than usual thinking. It’s also linked with poor outcomes. But it’s of course harder for people to notice, since there’s little “raving” or restlessness to catch people’s attention.
What to do: Be alert to those signs of difficulty focusing and worse-than-usual confusion, even if your parent seems quiet and isn’t agitated. Tell the hospital staff if you think your parent may be having hypoactive delirium. In the hospital, it’s normal for older patients to be tired. It’s not normal for them to have a lot more difficulty than usual making sense of what you say to them.
3. Delirium is often missed by hospital staff.
Despite the fact that delirium is extremely common, it is often missed in hospitalized older adults, with some reports estimating it’s being missed 70% of the time. That’s because busy hospital staff will have trouble realizing that an older person’s confusion is new or worse-than-usual. This is especially true for people who either look quite old – in which case hospital staff may assume the person has Alzheimer’s – or have a diagnosis of dementia in their chart.
What to do: You must be prepared to speak up if you notice that your parent isn’t in his or her usual state of mind. Hypoactive delirium is especially easy for hospital staff to miss. Hospitals are trying to improve delirium prevention and detection, but we all benefit when families help out. Remember, no hospital person knows your parent the way that you do.
4. Delirium can be the only outward sign of a potentially life-threatening problem.
Although delirium can be brought on or worsened by “little things” such as sleep deprivation or untreated constipation, it can also be a sign of a very serious medical problem. For instance, older adults have been known to become delirious in response to urinary tract infections, pneumonia, and heart attacks.
In general, it tends to be older persons with dementia who are most likely to show delirium as the only outward symptom of a very serious medical illness. But whether or not your older relative has dementia, if you notice delirium, you’ll want to get a medical evaluation as soon as possible.
What to do: Again, if you notice new or worse-than-usual mental functioning, you must bring it up and get your parent medically evaluated without delay. For older adults who are at home or in assisted -living, you should call the primary care doctor’s office, so that a nurse or doctor can help you determine whether you need an urgent care visit versus an emergency room evaluation.
5. Delirium often has multiple underlying causes.
In older adults with delirium, we often end up identifying several problems that collectively might be overwhelming an older person’s mental resilience. Along with serious medical illnesses, common contributors/causes for delirium include medication side-effects (especially medications that are sedating or affect brain function), anesthesia, blood electrolyte imbalances, sleep deprivation, lack of hearing aids and glasses, and uncontrolled pain or constipation. Substance abuse or withdrawal can also provoke delirium.
What to do: To prevent delirium, learn about common contributors and try to avoid them or manage them proactively. For instance, if you have a choice regarding where to hospitalize your parent, some hospitals have “acute care for elders” units that try to minimize sleep deprivation and other hospital-related stressors. If your parent does develop delirium, realize that there is often not a single “smoking gun” when it comes to delirium. A good delirium evaluation will attempt to identify and correct as many factors as possible.
6. Delirium is diagnosed by clinical evaluation.
To diagnose delirium, a doctor first has to notice – or be alerted to – the fact that a person may not be in his or her usual state of mind. Experts recommend that doctors then use the Confusion Assessment Method (CAM), which describes four features that doctors must assess. Delirium can be diagnosed if a patient’s symptoms include “acute onset and fluctuating course,” “difficulty paying attention,” and then either “disorganized thinking” or “altered level of consciousness.”
Delirium cannot be diagnosed by lab tests or scans. However, if an older adult is diagnosed with delirium, doctors generally should order tests and review medications, in order to identify factors that have caused or worsened the delirium.
What to do: Again, the most important thing for you to do is to get help for your loved one if you notice worse-than-usual confusion or difficulty focusing. Although families have historically not had a major role in delirium diagnosis, delirium experts have developed a family version of the CAM (FAM-CAM), which is designed for non-clinicians and has been shown to help detect delirium.
7. Delirium is treated by identifying and reversing triggers, and providing supportive care.
Delirium treatment requires a care team to take a three-pronged approach.
- Health providers must identify and reverse the illness or problems provoking the delirium.
- They have to manage any agitation or restless behavior, which can be tricky since a fair number of sedating medications can worsen delirium.
- The safest approach is a reassuring presence (family is best, but hospitals sometimes also provide a “sitter”) to be with the person, plus improve the environment if possible (e.g. a room with a window and natural light).
- The once-popular practice of physically restraining agitated older adults has been shown to sometimes worsen delirium, and should be avoided if possible.
- The care team needs to provide general supportive care to help the brain and body recover.
What to do: The reassuring presence of family is often key to providing a supportive environment that promotes delirium recovery. You can also help by making sure your loved one has glasses and hearing aids, and by alerting the doctors if you notice pain or constipation. Ask the clinical team how you can assist, if restlessness or agitation are an issue. Bear in mind that physical restraints should be avoided, as there are generally safer ways to manage agitation in delirium.
8. It can take older adults a long time to fully recover from delirium.
Most people are noticeably better within a few days, once the delirium triggers have been addressed. But it can take weeks, or even months, for some aging adults to fully recover.
For instance, a study of older heart surgery patients found that delirium occurred in 46% of the patients. After 6 months, 40% of those who had developed delirium still hadn’t recovered to their pre-hospital cognitive abilities.
What to do: If your parent or someone you love is diagnosed with delirium, don’t be surprised if it takes quite a while for him or her to fully recover. It’s good to be prepared to offer extra help during this period of time. You can facilitate recovery by creating a restful recuperation environment that minimizes mental stress and promotes physical well-being.
9. Delirium has been associated with accelerated cognitive decline and with developing dementia.
This is unfortunate, but true, especially in people who already have Alzheimer’s or another type of dementia. A 2009 study found that in such persons, delirium during hospitalization is linked to a much faster cognitive decline in the following year. A 2012 study reached similar conclusions, estimating that cognition declined about twice as quickly after delirium in the hospital.
In older adults who don’t have dementia, studies have found that delirium increases the risk of later developing dementia.
What to do: Experts aren’t sure what can be done to counter this unfortunate consequence of delirium, other than to try to optimize brain well-being in general. (For this, I suggest avoiding risky medications, getting enough exercise and sleep, being socially and intellectually active, and avoiding future delirium if possible.)
The main thing to know is that delirium has serious consequences, so it’s often worth it for a family to be careful about surgery in an older person, and it’s good to learn about delirium prevention (see below).
10. Delirium is preventable, although not all cases can be prevented.
Experts estimate that delirium is preventable in about 40% of cases. Preventive strategies are meant to reduce stress and strain on an older person, and also try to minimize delirium triggers, such as uncontrolled pain or risky medications.
In the hospital setting, programs such as the Hospital Elder Life Program (HELP) for Prevention of Delirium have been shown to work. For ideas on how families can help, see this family tip sheet from the Hospital Elder Life Program. For instance, families can help reorient a relative in the hospital, ensure that glasses and hearing aids are available, and provide a reassuring presence to counter the stress of the hospital setting.
Less is known about preventing delirium in the home setting. However, since taking anticholinergic medications (such as sedating antihistamines) has been linked with hospitalizations for confusion, you can probably prevent delirium by learning to spot risky medications your parent might be taking.
What to do: To prevent hospital delirium, carefully weigh the risks and benefits before proceeding with elective surgery. If your parent must be hospitalized, choose a facility using the HELP program or with an Acute Care for Elders unit if possible. Be sure to read HELP’s tips for families on preventing hospital delirium.
Remember, delirium is common and can be the only outward sign of a serious medical problem.
By educating yourself and helping your older loved ones be proactive about prevention, you can reduce the chance of harm from this condition.
And if you do notice symptoms of delirium, make sure to tell the doctors! This will help your parent get the evaluation and treatment that he or she needs.
Useful Online Resources Related to Delirium
Here are links to some of the resources I reference in the article:
- A study (one of many) finding that delirium is linked to worse health outcomes in the elderly
- A study of older adults in the Intensive Care Unit, finding that 43.5% had hypoactive delirium
- An article finding that older patients do better when they are hospitalized in an “Acute Care for Elders” unit (a special hospital ward tailored towards protecting older adults from hospital complications; they are great!)
- An explanation of the Confusion Assessment Method, which experts recommend doctors use to diagnose delirium
- A description of the Family-CAM, which experts developed to help family caregivers detect delirium
- A study finding that delirium accelerates cognitive decline in Alzheimer’s; a follow-up study finding that people with dementia decline twice as quickly after having delirium (!) is here.
- Tips on how family caregivers can prevent delirium, from the Hospital Elder Life Program
Last but not least, for my previous posts on delirium:
- Delirium: How Caregivers Can Protect Alzheimer’s Patients
- Hospital Delirium: What to Know and Do
- How to Maintain Brain Health: the IOM Report on Cognitive Aging
If you have any additional questions regarding delirium, please post them below!
This article was first written by Dr. Kernisan in July 2015, and was reviewed and updated in August 2023.
Mary Jo Disler says
Delirium in my husband about 5 years ago during a very lengthy hospitalization caught us completely by surprise. In my opinion, it should be described – at least the basics – to all patients & families of elderly age. I visited daily at the time. One day he seemed atypically combative. Eventually I left for home. In the night a nurse called to say they had to restrain him. Given his behavior of that day, I agreed. Next day when I went into his room, noticed heavy leather straps lying on the side (no longer attached to him. ) It was shocking, to say the least. It was quite some time before someone at the hospital described delirium, and I finally knew what it was. Again, this topic should be discussed, somehow presented respectfully as a possibility especially to families & patients of advanced years. Thank you for this article.
Nicole Didyk, MD says
That must have been a very frightening experience for you, Mary Jo and thanks for sharing it.
I agree that delirium awareness is important, especially when an older adult is admitted to hospital. This is an article that Dr. K wrote about hospital delirium: https://betterhealthwhileaging.net/hospital-delirium-what-to-do/
Kunal says
Hi My grandfather is 94 yrs old he went through slight paralytic attack 2 yrs back but recovered from it he is under heavy doses of medicine as he has many underlying diseases.But nowadays he suddenly starts talking nonsense and talking that somebody will kill us,or you all are planning something or somebody is there so can you help me a bit about this situation?
Leslie Kernisan, MD MPH says
It’s possible that he is developing some cognitive impairment. You can learn more about the causes and how to have it checked here: Cognitive Impairment in Aging: 10 Common Causes & 10 Things the Doctor Should Check
Wiskey says
Does this include saying things like “they are not going to let us out of here” &/or “they are going to kill us” said while in the hospital?
Those things freak me out & not sure what to do or say. Any suggestions are appreciated.
Thank you
Nicole Didyk, MD says
It would be very upsetting to hear these kinds of comments.
I would suggest validating the person’s point of view, which doesn’t mean you have to agree with them, just agree that you believe their perceptions are real to them. Offering simple, reassuring statements can be helpful (“you’re safe here”, “no one wants to hurt you”), and then trying to distract the person is another approach.
Being in hospital can be frightening so if you’re able to visit and be a familiar, friendly face, that could help a lot.
Pranab Kumar Bhattacharyya says
Hi,
I am Pranab from India,
My mother is 86 years old and bed ridden for past two years due to her difficulty in walking and she is unable to do any physical work. She is now completely dependent for her daily needs and my elder brother and sister in law are taking care of her to the maximum possible extent round the clock
My mother only answers very weakly when asked and can’t communicate well. Doctors say that these are all old age issues. However very recently she is continuosly calling them every minute for no reason or therr may be some reason that she can’t express Doctors say that this is an age related mental issue. There is no visible additional physical ailments. Is there any medication available to reduce or avoid her continuos call even when people are besides her?
Your valuable comment will be a great help.
Nicole Didyk, MD says
Hello Pranab.
You don’t mention if your mom has a diagnosis of dementia, but the behavior you describe is often seen in those living with Alzheimer’s or another type of dementia. You can read more about dementia and behavior here: https://betterhealthwhileaging.net/how-to-manage-difficult-alzheimers-behaviors-without-drugs/.
I think you’re on the right track looking for other causes of her distress. There may not be a physical ailment but if your mom is bored, lonely, overstimulated, or tired for example, she may be responding to that feeling by calling for help.
This article offers some advice about how to respond to the constant calling out: https://dailycaring.com/14-ways-to-handle-screaming-and-crying-in-dementia/
Robert says
These are from a journal I started after I was diagnosed with cancer in December 2022.
Am I delusional or psychotic or something completely different?
January 10, 2023
Yesterday I had all the symptoms of delirium except loss of bladder/bowel control. For the most part it was euphoric. I went for a drive which I probably shouldn’t have done but it was the most pleasurable driving experience I have ever experienced. I could go on and on about the drive it was so wonderful. My euphoria continued after my drive. I had a nurse call to ask how I was feeling and I talked for 22 minutes. Generally I’m an introverted person. When my wife got home (I messaged her about being home early if she could) I still had plenty of euphoria left. We haven’t been that close since probably before my 2015- present cardiovascular disease. However, when night came and I needed to switch off my brain it wasn’t possible. I thought surely I would “burn out” and fry my brain if it didn’t stop. I took a Xanax and within 15 minutes my brain had slowed to a single topic. Shortly after I fell asleep.
My cognitive functioning was possibly enhanced beyond anything I have ever experienced. However, as the day wore on I began to tire and the cognitive impairment returned and I could barely finish a thought.
January 11, 2023
I haven’t been very physical today. I’m not tired or sore or even disinterested. I just haven’t had the time to get up and do anything besides my toiletries and coffees. I have fancied myself to the likes of Shakespeare with my newly found ability to forge colorful writings from mundane topics like sclc. In other words (because I have no idea what I just wrote meant) I’ve been writing. I think I might actually be a good writer, perhaps closer to da Vinci than Shakespeare. Of course I’m joking. I think it’s funny.
I also decided whether I was producing writings of pure genius or they were just the utter rantings of a lunatic, that either way they were my writings. This means they were not written for you. Nothing here is about you. You may read my writings and even learn about me and what I’ve learned. However, you have not been granted permission to review, critique or even spell check my writings. This allows me to write how I feel is correct. If I had to write what you felt was correct I wouldn’t be able to share nearly as much of myself with you. So maybe I was mistaken maybe it is about you I mean like I already know what I’m writing about but you won’t know anything about what I’ve written until after you’ve read my writings.
From everything I’ve read about delirium it will probably not be permanent. It may come and go during some stages of treatment and recovery. I’m hoping that I can control the direction of my focus. There are other things I should be focusing on besides these writings.
The day has slipped away with the light and the moon continues to play coy with her brilliance.
I think today the roller coaster ride we have named Treatment is nearing the finish the process of braking squeals as we enter the final valley of her mighty maze. Here all is calm and relaxed with the distant clunk of the chains as they heave the next caravan of souls into the heavens above only to free fall through the darkness of shafts and twists. Some turns are so intense you think you might be thrown from the sky while holding a useless bar that failed to secure your ass. And everything repeats.
January 13, 2023
I feel more tired today than I have since the delirium started. More like myself, more forgetful and less motivated. However, I did manage to find an article about how to differentiate psychosis from delirium.
Psychosis should be differentiated from delirium; a person suffering from psychosis may still be able to perform higher cognitive functions, whereas a person suffering from delirium will have impaired memory and impaired cognitive functions.
Given this difference then I should hope that these past few days have been the ravings of a lunatic rather than that of genius!
I’m not sure how I feel about this. On the one hand I’d hate to be considered psychotic and on the other hand I’d also hate to have spent so much time writing gibberish.
Nicole Didyk, MD says
It’s a great idea to keep a journal of your feeling sand experiences, especially while on a journey with cancer.
It is unusual for a person with delirium to have such clear insight while in the midst of it. although many recall elements of the delirious episode, usually in a fragmented way. Delirium is marked by loss of concentration or attention, fluctuates, and often causes drowsiness or hyperalertness.
Medication (for example corticosteroids or narcotics) can produce side effects like euphoria, insomnia and even hallucinations (psychosis).
It’s important to let your care team know what you’re noticing, as the changes may be related to your condition or its treatment.
Alison Hughes says
Hi Leslie
I wonder if you can help please.
My 93 year old (3rd) cousin returned from a 2 month stay in 2 hospitals (Dec to Feb this year) I now know having read medical notes she had delirium hence why she appeared confused. Hospital notes also repeatedly syated she had known mild cognitive confusion. On 17th Feb she came home with support of 4 visits per day from a care company. Amongst the notes it is stated on several occasions she was confused & even believed she saw people that weren’t there. On 1st April however, unbeknown to me it was arranged for a solicitor to visit her & subsequently her will was changed. She sadly passes away on 22nd April.
I visited & spoke to her somexe days later & discussed the solicitors visit but she couldn’t remember this taking place. I have been told that all correct procedures were carried out ie the sames questions were asked as hospital staff would & that if the person appears not confused on that particular ie day ‘having a good day’ then any condition that might effect their mental capacity the rest of the time is irrelevant.
I really would appreciate your opinion please. Thank you. Alison
Nicole Didyk, MD says
Sorry to hear about the loss of your cousin.
If a person has delirium, there can be periods of lucidity, such that they could direct their care or give instructions about a will or other major decisions. Even if a person is living with dementia, they could be capable of some decisions and incapable of others. The capacity needs to be assess in the moment, by the person helping with the legal or financial process (like a lawyer). Capacity is a tricky thing to assess and understand as I discuss in this vifeo:https://youtu.be/Gnlxbp1qi0o
In the situation you describe, the solicitor should have assessed your cousin’s capacity before making the changes to the will. It can be a challenge to try to retrospectively determine if a person was capable or not at a particular point of time and would probably rely on ay documentation that was made at the time.